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Reducing Interprofessional Conflicts in Order to
Facilitate Better Rural Care: A Report From a 2016
Rural Surgical Network Invitational Meeting
Hayley PELLETIER*
11 Student, University of British Columbia, Canada
* Auteur(e) correspondant | Corresponding author : hpell088@uottawa.ca
Résumé :
(traduction)
Le Centre sur la recherche en santé rurale a tenu une réunion sur invitation pour faciliter les discussions avec les chirurgiens généraux en Colombie-Britannique; l’objectif était de bien comprendre leurs préoccupations et traiter des questions portant sur les médecins de famille qui possèdent des compétences chirurgicales avancées (FPESS). En particulier, la réunion a porté sur les défis interprofession-nels qui nuisent à l’adoption d’un modèle de réseau entre les chirurgiens géné-raux et les FPESS. Ce rapport résume les conclusions (n = 5) et les recommanda-tions (n = 8) qui ont été formulées lors de la réunion. La réunion a démontré le besoin d’avoir davantage de discussions réfléchies afin d’établir un climat de con-fiance et d’assurer le support interprofessionnel entre les chirurgiens généraux et les FPESS au moyen d’un système de soins de santé intégré et de réseaux adé-quats.
Mots-clés :
Rural, services de santé en milieu rural, FPESS, chirurgien général, Colombie-Britannique, réseauAbstract:
An invitational meeting organized by the Centre for Rural Health Research con-vened to facilitate respectful dialogue with general surgeons in British Columbia; the objective was to clearly understand concerns and address questions around rural family physicians with enhanced surgical skills (FPESS). In particular, the meeting focused on interprofessional challenges that hinder the adoption of a net-work model between general surgeons and FPESS. This report summarizes the findings (n = 5) and recommendations (n = 8) made during the meeting. The meeting underscored the need for more thoughtful discussions to develop inter-professional trust and support between general surgeons and FPESS through an integrated health care system and proper networks.Introduction
In response to decreased provision of surgical and maternal health services in rural areas, family physicians with en-hanced surgical skills (FPESS) are filling the gap by provid-ing appropriate and effective care to rural residents (Kornelsen & Friesen, 2016; Kornelsen, Iglesias, & Wool-lard, 2016a; Kornelsen, Iglesias, & WoolWool-lard, 2016b). For family physicians to be certified as having enhanced surgi-cal skills (ESS), they must first receive training at the Uni-versity of Alberta, AB, Canada. The program titled “Enhanced Skills” is the only program in Canada that pro-vides students with procedural skills training in areas such as caesarean section, endoscopy, and carpel tunnel repair. Although the ESS program is an innovative solution to the lack of surgeons practicing in rural areas, graduates of the ESS program have reported interprofessional difficulties regarding “turf wars” with general surgery colleagues that act as a barrier to the provision of necessary and appropri-ate care (Kornelsen et al., 2016a; Iglesias et al., 2015; Kor-nelsen et al., 2016b). In order to improve interprofessional relationships and reduce rural health care inequities, this invitational meeting aimed to provide a platform for general surgeons to express their concerns regarding ESS practice. Concerns identified during the event were noted and ana-lyzed in an effort to develop a solution that is satisfying to both FPESS and general surgeons.
Background
A specialized professional culture characterized by exper-tise, controlled resources, and clearly set boundaries has been shown to lead to increased isolation of general practi-tioners (GPs) and specialists (Manca, Breault, & Wishart, 2011). Comparatively, a comprehensive professional culture characterized by the negotiation of boundaries to achieve relationship-building and effective collaboration, has been shown to contribute positively to the work culture amongst GPs and specialists. In addition, a comprehensive profes-sional culture puts emphasis on mutual empowerment of generalists and specialists, fostering a greater level of col-laboration (Kornelsen et al., 2016a; Kornelsen et al., 2016b) Although these “turf war” conflicts seem to occur naturally in a clinical environment, studies have shown that through increased dialogue and interaction, it is possible to signifi-cantly improve interprofessional relationships. This should be encouraged as it is believed to foster mutual understand-ing and respect (Marshall & Philips, 1999).
Baxter and Brumfit (2008) recommend that in order to change what has traditionally been deemed
“professionalism,” a whole-systems approach must be
adopted. This approach involves redefining what society views as a profession and the roles attributed to the given “profession.” The authors identified an important distinc-tion between team identity and professional identity; the difference being that teams have important factors such a size and regular contact, that aid in creating a sense of be-longing.
Within the academic literature, networks of care have been proposed as another potential solution to traditional hierar-chical models (Addicott, McGivern, & Ferlie, 2010). A net-work of care refers to the collaboration of low-resource lev-els of care, secondary care, and tertiary care in the provision of health services. In essence, a referral hospital — usually secondary or tertiary care in a mid-sized city — will act as an outreach extension for rural health services that would otherwise not be sustainable (Addicott et al., 2010; Kornel-sen & FrieKornel-sen, 2016). The case for networks of care is rooted in the belief that with this model, knowledge can transcend boundaries. Networks have therefore been viewed as an op-portunity for two-way knowledge sharing.
Using NHS Cancer Network as a case study, Addicott et al. (2010) highlighted the importance of creating a network of care. They reported that emphasis must be placed on natu-rally occurring relationships and an increase in support and initiatives for these relationships. Organic relationships were found to be the most successful because they are root-ed in socialization and trust, which are vital to the for-mation of genuine communities of practice. Managed net-works, which placed a higher importance on performance, were unsuccessful. It is suspected that this is because there was a significant focus on competition and following proto-cols which outweighed the need for knowledge exchange and the overall growth of the network to provide better care (Addicott et al., 2010). Another significant barrier to imple-menting a network of care is the attitudes of clinicians. In this study, clinicians frequently reported feeling that they had nothing to gain or learn from others and therefore would not participate in a network.
The objective of this Rural Surgical Network Meeting was to facilitate respectful dialogue with General Surgeons in Brit-ish Columbia to clearly understand concerns and address questions around rural FPESS.
Meeting structure and purpose
An invitational meeting hosted by the Centre for Rural Health Research and in part by the Rural Coordination Cen-tre of BC titled “Rural Surgical Networks,” took place on November 28th, 2016 in Vernon, British Columbia. The ini-tiative consisted of subject matter experts from the
Canadi-an Association of General Surgeons (CAGS) membership and practicing rural general surgeons. The event began with a review of the meeting goals and the agenda and was fol-lowed by invited presentations and discussions.
Invitees consisted of subject matter experts and key policy stakeholders, together representing a wide range of inter-ests. The core goal of the meeting was to clearly understand the general surgeons’ concerns about FPESS and address questions surrounding rural FPESS, in order to identify barriers that hinder the development of a rural surgical net-work between the two professional groups.
Two keynote presentations provided context on the history of rural health services and FPESS, as well as insight into future innovations. Following the presentations were ques-tion and discussion periods, lasting approximately 60 minutes in length. Notes taken by a scribe throughout the meeting were then summarized and synthesized by the au-thor to develop policy-relevant findings and recommenda-tions.
Findings and recommendations
Networks of health service delivery involving key “coaches” have been developing throughout rural Canada as a poten-tial solution to rural health disparities, which result in part from the attrition of rural surgical and maternity services. When this model was presented to the invited surgeons, four main barriers were identified. Key findings and recom-mendations from the meeting participants are summarized herein and in Table 1.
Barrier 1 — The Role of Semi or Fully Retired Surgeons Participants discussed the role of partly or fully retired sur-geons taking part in the network model as potential coaches because of their increased availability compared to full-time surgeons. Key players expressed that although retired or semi-retired surgeons may have more time to commit to the network model of care, full-time non-retired surgeons are preferred and are better suited. The role of a coach is in part to connect the general surgeons to a larger network of sur-geons and to be a reliable point of contact between regional referral centres. Naturally, this requires that the coach be a key player at the regional referral centre, something that would not effectively be possible with semi-retired or re-tired surgeons.
Barrier 2 — Unclear Role of a Coach
The participants expressed a sense of confusion regarding the role of a “coach.” It was evident from the discussions that took place that role clarification would be needed in order to move forward with a network model.
One expert expanded on his vision of the coaching role and the development that has already begun in British Colum-bia. He expressed that the responsibility of the coach is not to perform any sort of training, nor is it to teach general surgeons how to do procedures. Instead, it is a much-needed opportunity for general surgeons to feel supported by their colleagues. Coaches would therefore act as a sup-port system for FPESS, to help them improve upon the things that they are already trained to do.
Barrier Solution Target decision maker
(if applicable) The role of retired or semi-retired
surgeons Have full-time surgeons act as coaches rather than re-tired surgeons N/A
Unclear role of a network “coach” Develop a clear definition and distribute it to all general surgeons The network development team, and supported by various health authorities
The role of health authorities Integrate health authorities in the development of a net-work model of care in order to initiate a change in cul-ture and infrastruccul-ture
Health authorities throughout British Columbia
FPESS unrealistic expectations
Provide clarity to FPESS about the field of surgery in order to reduce unrealistic expectations and gain the
support of general surgeons FPESS program and its graduates
Remuneration and man power
Engage in further discussions about how the network model of care would recruit the necessary human re-sources and provide the general surgeons with appropri-ate remuneration
CAGS and the network development team
Identified barriers and solutions to adopting a supportive network model based on the participants’ perspectives.
Barrier 3 — The Role of Health Authorities
In British Columbia, health services are regulated by region-al heregion-alth authorities. The majority of participants feel that the main obstacle to creating and implementing a network model of care does not lay with the surgeons, but rather with the regional health authorities. Work must be done to integrate the health authorities into the conversation around networks as early on as possible in order to effec-tively change the current culture and infrastructure. A po-tential first step in this area could involve the inclusion of local administrative staff and nurses in the coaching pro-gram.
Barrier 4 — FPESS Unrealistic Expectations
Participants noted a concern towards unrealistic goals of general surgeons. Of the few general surgeons that the par-ticipants had dealt with, they found that more FPESS hold the belief that once they have completed their training, they will be as competent as a surgeon. The event participants noted a deep concern for this type of mentality and ex-pressed that they would require clear objectives from the network model program in order to get on board. Barrier 5 — Remuneration and “Man Power”
As a natural follow-up to the discussions regarding the role of general surgeons in adopting the network model, subse-quent discussions were held regarding what this would re-quire in terms of remuneration and human resources. The participants were far from uniform in their opinions on the two discussion points. Some participants overtly stated the need to be compensated in monetary format for the time committed to the new model of care, while others disagreed, stating that the financial repayment would work itself out and that a larger focus should be placed on the human re-sources available to take-on coaching roles. It is evident that the discussion around remuneration and available human resources will require input from a larger sample of sur-geons in order to draw an appropriate conclusion.
Moving forward
Rural surgical networks are an emerging potential solution to the various challenges of providing sustainable, local care in rural British Columbia. The actualization of the model is fraught with challenges inherent in low resource environ-ments, including lack of timely access to specialist and ma-ternal care, and difficulty maintaining competence and con-fidence due to low procedure volume. Findings from the invitational meeting suggest focusing on the following steps in order to enable the reduction of rural health inequities through the introduction of a rural surgical network.
1. Discuss scope of practice at the CAGS level.
2. Develop trust that is natural and instinctive by facili-tating and encouraging surgeons to visit rural sites. It is anticipated that this will allow for a better under-standing of the situation and resources.
3. Involve CAGS and health authorities as early on as possible in order to scale ideas and provide support.
Conclusion
The possibility of British Columbia adopting a network model of care has shed light on issues regarding privileging of FPESS and general surgeons to the forefront of
healthcare research as well as health policy. The 2016 Invi-tational Rural Surgical Network meeting focused on topics related to the concerns of general surgeons in adopting the network model and engaging as “coaches.” Realizing the potential of networks in improving rural health inequities and moving it from an idea to routine practice will involve addressing a number of important barriers. The recommen-dations emerging from the meeting underscore the need for more thoughtful discussions to develop the interprofession-al trust and support between generinterprofession-al surgeons and FPESS through an integrated health care system and proper net-works of care.
Acknowledgements
The author would like to express sincere thanks to the fol-lowing people who helped make this a successful event and for providing the facilities needed to conduct the research: Dr. Jude Kornelsen, Dr. Stuart Iglesias, Dr. Garth Warnock, and Dr. S. Morad Hameed.
The author would also like to thank all the participants at this meeting for their valuable contributions to this im-portant discussion. The opinions expressed in this docu-ment are those of the author and do not necessarily reflect the official positions of the Canadian Association of General Surgeons.
Funding
This meeting was funded by the Shared Care Committee, a joint committee of Doctors of BC and the BC Ministry of Health.
References
Addicott, R., McGivern, G., & Ferlie, E. (2006). Networks, organizational learning and knowledge management: NHS cancer networks. Public Money and Management, 26(2), 87-94. doi:10.1111/j.1467-9302.2006.00506.x
Baxter, S. K., & Brumfitt, S. M. (2008). Professional differ-ences in interprofessional working. Journal of
Interprofes-sional Care, 22(3), 239-251.
doi:10.1080/13561820802054655
Iglesias, S., Kornelsen, J., Woollard, R., Caron, N., Warnock, G., Friesen, R., . . . Mazowita, G. (2015). Joint position paper on rural surgery and operative deliv-ery. Canadian Journal of Rural Medicine, 20(4), 129-38. Kornelsen, J., & Friesen, R. (2016). Building rural surgical networks: An evidence-based approach to service delivery and evaluation. Healthcare Policy, 12(1), 37-42.
Kornelsen, J., Iglesias, S., & Woollard, R. (2016a). Rural perinatal surgical services: Time for an alliance between providers. Journal of Obstetrics and Gynaecology
Cana-da, 38(2), 179-181. doi:10.1016/j.jogc.2015.12.017
Kornelsen, J., Iglesias, S., & Woollard, R. (2016b). Sustain-ing rural maternity and surgical care Lessons
learned. Canadian Family Physician, 62(1), 21-23.
Manca, D. P., Breault, L., & Wishart, P. (2011). A tale of two cultures Specialists and generalists sharing the
load. Canadian Family Physician, 57(5), 576-584.
Marshall, M. N., & Phillips, D. R. (1999). A qualitative study of the professional relationship between family physicians and hospital specialists. The Professional Geographer, 51 (2), 274-282. doi:10.1111/0033-0124.00164
